Provider Demographics
NPI:1518146950
Name:POTTLE, THOMAS G (M D)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:POTTLE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5305 WRIGHTSVILLE AVE STE K
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6507
Mailing Address - Country:US
Mailing Address - Phone:910-452-2175
Mailing Address - Fax:910-452-1962
Practice Address - Street 1:5305 WRIGHTSVILLE AVE STE K
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6507
Practice Address - Country:US
Practice Address - Phone:910-452-2175
Practice Address - Fax:910-452-1962
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28411208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC212629CMedicare PIN